- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $639.89 / $825.33 / $868.61
| Professional | | $639.89 | $825.33 | $868.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,070.64 / $2,796.68 / $3,310.94
| Facility | | $2,070.64 | $2,796.68 | $3,310.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.20 / $769.65 / $1,287.19
| Professional | | $654.20 | $769.65 | $1,287.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.11 / $1,036.33 / $1,036.33
| Facility | | $847.11 | $1,036.33 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.53 / $1,036.33 / $1,036.33
| Professional | | $756.53 | $1,036.33 | $1,036.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.36 / $836.38 / $1,217.73
| Professional | | $660.36 | $836.38 | $1,217.73 |